Pubovaginal Slings using
Fascia Lata for the treatment of intrinsic sphincter deficiency.
Govier, F.E. ; Gibbons, R.P. ; Correia, R.J. ; Weissman. ; Pritchet, T.R. and Hefty, J.R.
From the section of Urology and Renal Transplantation, Virginia Mason Medical Center,
Seattle, Washington. J. Urol., v.157, p.117-21,1997.
Purpose: Various material
and techniques have been used to construct a pubovaginal sling. We believe that fascia
lata has several advantages and report our experience.
Materials and Methods: A total of 32 female patients with urodynamically proved
intrinsic sphincter deficiency underwent a pubovaginal sling procedure using fascia lata.
An unscarred fascial strip 24 to 28 X 2 cm. Was attached to itself over a 3 a 4 cm. bridge
of abdominal wall fascia (Figure 1, 2,
3, 4) . Results were tabulated by chart review and na
independent patient survey.
Results: Chart review revealed that 28 of 32 patients (87%) required no pads, and 3
improved and 1 did not. An independent patient survey revealed that 70% of patients (21 of
30) required no pads, 20% required 1 to 3 small pads and 10% required more than 3 small
pads per day. Of the patients 80% would undergo the procedure again.
Conclusions: Excellent results can be obtained with fascia lata for the treatment
of intrinsic sphincter deficiency. A long , wide strip of fascia attached to itself allows
for precise tensioning and good urethral closure, and minimizes the risk of obstruction.
Urinary incontinence in women caused by intrinsic
sphicterian deficiency (ISD) is traditionaly treated with a pulbovaginal sling. Since the
beginning of the century many surgical materials and techniques have been proposed, the
most used being the aponevrotic strip from the abdomen anterior rectum, using
double surgical route approach, this means, abdominal and vaginal way.
These techniques were mostly forgotten for a certain period of time, but recently have
been rescued and made popular, mainly after the work of McGuirre & Lytton, 1978 1.
In the discussed article the authors present the results of the 32 patients underwent a
pubovaginal sling procedure using fascia lata with ISD. The majority had been submited to
The results of the surgical evaluation are:
Excellent (patients that are completely
Good (slight leak without need of pads);
Improved (needs a change of 2 or 3 pads a day) ;
Failure (needs more than 3 pads changes a day).
The authors present the surgical results with 2
methods of evaluation. The first method consists of written answers given by the patients
to a questionary that was handed to them. The second method of the evaluation resulted in
a telephone interview by a clinical nurse.
It calls to our attention the great disparaty of the answers obtained by both methods. The
differences of the evaluation between the 1st. and 2nd. method were the following,
respectively: Excellent - 78 and 33%; Good - 9 and37 %; Fair - 9 and 20%; Failure - 4 and
The follow up of continuation was relatively short, varying from 3 to 33 months, with an
average of 14 months.
The authors consider themselves satisfied with the results they obtained and they
emphasized the following advantages with the use of the fascia lata :
The fascia lata supplies a long
aponevrotic strip (18 to 22 cm.) with a good thickness, an absence of scars,
permitting good technical conditions for the carrying out of the "sling"getting
an excellent urethral closing with a low risk of obstruction;
Because there is no removal of abdominal fascia,
hospitalization is short, there is no risk of formation of abdominal hernia and returning
to activities is sooner (4 weeks).
One important technical aspect discussed in this
article refers to the degree of tension that is given to the aponevrotic strip and
the possibility of this tension to be raised gradually at the cost of suture stitches,
till you reach a desired tension.
However what must be evident is that the authors do not present an objective parameter to
establish the adequate degree of tension to each case. That is the critical point of all
"sling" techniques and the tension given to the aponevrotic strip or any
other material, always have an extremely subjective component.
The lack of tension, or the contrary, excessive tension, are factors that cause the
persistency of urinary incontinence leading to the failure of those techniques, or then,
the occurrence of urinary obstruction in the post-operatory of these surgeries, that need
an indication of intermitent catheterism for long periods of time.
The non adequate solution of the critical point of this surgical technique certainly is
responsible for the elevated number of non satisfactory results, because, 67% of these
patients (if we compute the 2nd method of the authors evaluation) will continue to present
urinary leak of a lesser or higher magnitude.
Josť Carlos Souza Trindade
1. MC GUIRE, E.J.;
LYTTON,B. Pubovaginal sling procedures for stress incontinence. J. Urol., v.119, p.82,